PRESCRIBING BETTER “PILLS” TO SWALLOW

By Alicia Fung

A visit to your family doctor may end with a prescription for medication. But what if, instead of medication, you were prescribed a choir class?

This was one of the unconventional prescriptions that Nafisa Nezam Omar had received from her family doctor at Rexdale Community Health Centre (CHC). But perhaps an unconventional prescription was just what Nafisa needed, considering her journey in coming to Toronto.

Nafisa and her daughter came to Canada from Kabul as asylum seekers in 2017. After losing her sister and her home to a rocket attack, her brother to gunfire, and her husband to a heart attack, she packed her life into one suitcase and fled the country with her daughter. The grief of losing her loved ones and everything she once knew, compounded with the stress of starting anew in an unfamiliar country, took a heavy toll on Nafisa’s health.

“A few weeks after I came to Canada, I found this small space in the basement of a bungalow house. There weren’t any bedrooms—it was just a small room. I looked at what I had compared to what I had in Kabul, and I missed my parents, my brothers and sisters, my loving husband, my job—everything. And after living in Toronto for 10 months, I lost 15 kilograms of weight. My family doctor was really concerned, sending me for every kind of examination thinking that it was possibly cancer,” says Nafisa.

After several consultations and examinations, Nafisa was diagnosed with post-traumatic stress disorder. She was prescribed anti-anxiety medication, antidepressants and sleeping pills, among other medications to help her manage her health. Despite this, nothing seemed to help. In fact, to Nafisa, it seemed that the medicines were making her feel worse, making it even more difficult for her to provide for herself and her young daughter in a new country.

“I was taking so many medicines and each one of them has its own side effects. I put them all in front of me and just looked at them, thinking that although I’m living with the help of all these medicines, it’s giving me more pain and depression,” she says. “But it wasn’t just me having a hard time—all of this really affected my daughter as well. She was only 10 years old when we came to Canada and she was also suffering. She was being bullied in school, her marks were bad, and she was looking to me for support but I couldn’t help her because of my health.”

In 2018, Nafisa finally received a prescription that made all the difference. It wasn’t a prescription for more medication, but rather, a social prescription. But what exactly is a social prescription?

Health is not only influenced by genetics, biology, and lifestyle, but also by a broad range of social, environmental and economic factors. These factors are collectively known as the social determinants of health. Research has shown that the social determinants of health can have a greater impact on health than individual biology, driving between 80 to 90 per cent of health outcomes. Yet, while many primary care professionals are aware of this fact, it can seem difficult to address social needs in clinical practice. Social prescribing helps health professionals support their patients by giving them the tools to formally connect social care and clinical care. By meaningfully “prescribing” social services and resources as they would medicine, primary care professionals can practically address the social needs of people in their practices.

“Family doctors are specialists in the relationship. When we’re building relationships with people, we often see things that have a huge impact on health, but aren’t the classic medical factors that people think of in the medical model. These are things like food security, housing, income, social connection or social safety nets. Social prescribing is about recognizing that these things come out of the relationships that we build with people and looking at how we can address these social needs in day-to-day practice,” says Dr. Dominik Nowak, a family doctor and an Assistant Professor at the University of Toronto Department of Family and Community Medicine (DFCM).

“If you’re a physician and you’re thinking about how you can support your patients in getting the supports they need, you have to navigate the system yourself and it’s not easy on your own. So, social prescribing looks at how we can improve the pathway and the processes so that clinical care and social care work better together. It’s just putting more tools in a physician’s toolbox,” says Dr. Jennifer Rayner, an Assistant Professor at DFCM. “If we think about this from a health equity lens, people experience barriers in our health care system in all sorts of ways. As one of the most trusted professionals in a person’s life, primary care professionals are in a position to recommend community and social services that can help to improve their patient’s health. So, by leveraging that trusted relationship with a physician and improving the pathway to accessing the programs and supports people need, primary care professionals can help to break down some of those barriers to access.”

So, instead of going to a pharmacist to fill her prescription as usual, Nafisa was referred by her family doctor to a social prescribing navigator who worked collaboratively with her to connect her with non-clinical, community-based supports based on her interests. In her case, the social prescription came in the form of a senior group at Rexdale CHC, where she joined a choir class, learned tai chi and exercised with a Zumba group, among many other activities. Being part of this group not only helped Nafisa find a community where she felt welcomed, but also helped improve her physical health immensely.

“I slowly stopped taking all the medicine and I was able to return to my normal weight. I also stopped having nightmares,” says Nafisa.

The social prescribing program at Rexdale CHC was part of a larger social prescribing pilot called the Rx: Community project led by the Alliance for Healthier Communities, where Dr. Rayner is Director of Research and Evaluation. Eleven CHCs across Ontario participated in the pilot project, in which 147 providers referred more than 1,100 clients to 3,295 social prescriptions. Participating clients noted that connections to non-medical interventions helped to reduce stress and anxiety, increase sense of self-confidence and purpose, and give them the knowledge and tools to better manage their own health. Overall, providers saw improvements to their clients’ health and wellbeing, and clients self-reported a 49 per cent decrease in feelings of loneliness, a 12 per cent improvement in mental health, and a 16 per cent increase in a sense of community belonging.

Source: Alliance for Healthier Communities

Although the word “prescribing” may imply a one-way relationship between a healthcare provider and a client, this is not the case with social prescribing. A core component of social prescribing is to invite clients to co-create solutions that are tailored to their interests and community. When people are involved in creating solutions for themselves, it gives them a sense of agency and empowerment over their own health.

“Some clients might have certain passions or skills and when we find or create spaces that support them in using those skills, they can then take the lead to create diverse programs and offerings for others. And I think that’s one of the most amazing pieces of social prescribing—sometimes the patients themselves become the solutions. Social prescribing moves beyond just looking at their presenting problems and asking them ‘What’s the matter with you?’ but instead asking them, ‘What matters to you?’” says Dr. Rayner, who is one of the authors of the Rx: Community project.

“There isn’t a one-size-fits-all approach. Different communities are impacted differently by the social and structural determinants of health, so social prescriptions are co-designed with patients and tailored toward community needs. It’s about listening and learning about what a person or a community is sharing is most important and would be helpful,” adds Dr. Nowak, who supported the project.

While social prescribing is a useful tool for primary care professionals, it is not a catch-all solution that replaces clinical care or robust social policies that address the social determinants of health on an upstream level. Social inequities come about because of structural issues in society and without working to try and shift those structures, it is unlikely that we will see a significant impact on the health of our communities. We cannot ignore, however, the downstream interventions for purely upstream ones, says Dr. Gary Bloch, a family physician and an Associate Professor at DFCM.

“I don’t think purely upstream interventions are enough, and certainly purely downstream interventions are not enough. We need to look at these issues from a broad understanding of what social needs are for patients, but also from a very practical perspective of what we can do dayto-day to deal with the very real social needs our patients present with. And it’s these day-to-day social needs that I think social interventions such as social prescribing are attempting to address. It’s giving physicians easy-to-understand and easy-to-implement tools to intervene in a patient’s social needs,” says Dr. Bloch.

Over the last few years, the social prescribing movement has been gaining traction as the medical community’s understanding of the underlying drivers of health continue to evolve. As we learn more about the social determinants of health and its influence on health inequity, medical schools have increased their commitment and investment in teaching future physicians about these topics and how they can respond to and advocate for the needs of their patients and communities beyond their clinical practice.

“I routinely feel like I’ve come across medical students and residents who have a far deeper understanding of social inequity than I ever have, and they really push my understanding of where we’re at and where we need to go in this work in incredibly powerful ways,” says Dr. Bloch. “We’re seeing new physicians joining us with a whole different level of comprehension of social issues and a whole different skillset for dealing with these issues, and I think this will really transform clinical practice well into the future.”

There is still much to learn about how health professionals can best support their patients faced with social challenges, but social interventions such as social prescribing have proven to be transformative for many people, including Nafisa and her daughter: “Every medicine has its own effect, but this social prescription was really like magic— especially for me, but also for my daughter. She is 16 now and she looks like she’s really enjoying her life. This program saved me from a period of worry and deep grief and brought me hope and thankfulness.”